[Evolution of surgical indications in upper limb functional surgery for tetraplegic patients: Retrospective study of 428 procedures]

Introduction: Regarding surgical strategy for upper limb functional rehabilitation in patients with traumatic tetraplegia, there are few publications and the case series are quite small.

Patients and method: We reviewed all traumatic quadriplegic patients, operated one by one surgeon, professor Marc Revol, for functional surgery of the upper limb in the same department from 1989 to 2018. For each patient, we recorded their gender, their group according to the international classification, their age at the time of the first surgical procedure, the length of time between the accident and the first surgery and between two procedures, the average duration of the whole surgical program, and the surgical technique used for the elbow, the wrist, the long fingers and the thumb.

Results: We reviewed 158 cases, representing 428 surgical procedures. Some surgical principles have remained unchanged through the years: the hand opening stage comes before the closing one, and systematically includes intrinsic active palliative procedures using lassos; and restoration of long fingers grasping is consistently associated with restoration of thumb gripping and with flexor tendons tenolysis in the lassos region. Other strategic points have evolved over time: restoration of active elbow extension now systematically uses the biceps over the deltoid transfer; brachio radialis (BR) to extensor digitorum communis (EDC) and to extensor pollicis longus (EPL) transfer has been replaced by tenodesis; in groups 2, 3, 4 and 5, the hand opening stage has been consistently associated with the biceps transfer, thus shortening the surgical program to two procedures instead of three for each upper limb; split distal flexor pollicis longus (FPL) tenodesis has replaced thumb arthrodesis; and, whenever it was possible, BR has been spared from group 3 and beyond.

Conclusion: In groups 2 to 5, the indications have evolved towards the following strategy. The first surgical step includes restoration of elbow extension using biceps transfer and hand opening reinforcement through four lassos, one split distal FPL tenodesis for the thumb, and EDC and EPL tenodesis to the retinaculum. The second surgical procedure consists of restoration of long fingers and thumb flexion using one unique motor (BR or extensor carpi radialis longus), and closed tenolysis of the flexor tendons in case of adhesions in the lassos area.